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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 10/15/2024
Date Signed: 10/15/2024 05:15:36 PM


Document Has Been Signed on 10/15/2024 05:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, JENNIFERFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 41DATE:
10/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Yvonne Golden, Lead Med TechTIME COMPLETED:
06:00 PM
NARRATIVE
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On 10/15/24 at 4:37PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to open a 10 day initial complaint on an unrelated matter and conducted a case management deficiency. LPA met with Yvonne Golden, Lead Med Tech, and explained the purpose of the visit.

During the initial 10 day complaint opening, LPA observed that R1 Physician Report (LIC602) is missing from R1's file. Staff contacted the Administrator via phone call and Administrator stated that R1 doesn't have a current Physician Report.

Regulations are cited from California Code of Regulations, Title 22, are being cited on the attached LIC809D. Therefore, this allegation is Substantiated.


Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 05:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: COUNTRY PLACE ASSISTED LIVING
FACILITY NUMBER: 075601547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2024
Section Cited
CCR
87458

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Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. ...LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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LPA observed the record file of R1 missing a medical assessment. Administrator agreed to get an updated medical assessment for R1 and provide a copy to the Department by the POC date via email.
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 This requirement is not met as evidenced by:
Based on observation, licensee failed to ensure that resident has a medical assessment maintained in records, which poses a potential risk to the health and safety of resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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